Anna Heard and Annette N. Brown
At the 21st International AIDS Conference (AIDS 2016), a biennial conference that was held in Durban, South Africa last month, there was a loud and clear call for HIV self-testing to play a key role in reaching the goal of 90 per cent of people living with HIV knowing their status – the first of UNAIDS’ 90-90-90 goals. Two years ago, at AIDS 2014 in Melbourne, Australia, the tone was different. HIV self-testing was discussed hopefully but cautiously. Several of the presented studies looked at acceptability, including this one for Kenya, but only a few studies provided evidence from the use of HIV self-tests, and none were impact evaluations. However, at this year’s conference, several studies, including three funded by 3ie, presented exciting new evidence from impact evaluations showing that HIV self-tests can indeed significantly increase HIV testing rates.
What is an HIV self-test?
An HIV self-test is a kit that people can use at home, collecting a blood or oral fluid sample to test, and reading the result themselves. Package instructions and health providers advise that if the test returns an HIV positive result, the individual should get re-tested at a health facility. The self-test process generally takes about 20-30 minutes. In a few countries, HIV self-test kits are available over the counter at pharmacies or through the internet or at health facilities. The hope is that self-testing will appeal to people who have been hesitant to access services through health professionals, even those using door-to-door methods. But widespread availability of self-test kits is still rare, as many country governments are still wary.
What’s the new evidence?
At AIDS2016, researchers presented the results of four separate impact evaluations estimating the effect of making HIV self-tests available, and all showed significant increases in HIV testing. 3ie funded three of these studies, all of which were implemented in Kenya. 3ie has been working closely with the Government of Kenya’s National AIDS and STI Control Programme, which is using this evidence to develop their new self-testing guidelines.
Two of the Kenyan evaluations assessed whether providing the HIV self-test kits to women attending postnatal and/or antenatal care clinics to give to their partners would increase partner testing. Both studies used individual randomisation to create comparable groups and reported large increases in partner testing. In one study, researchers found that, in the group where partners were offered self-test kits, overall HIV testing was 39 percentage points higher (91% vs. 52%). In the other, the offer of self-testing increased testing 54 percentage points compared to control (83% vs 28%). Some of the strongest results were among partners who had never tested before or not recently. The results of these two impact evaluations suggest that secondary distribution through a partner can reach individuals, particularly men, who have been reluctant to access standard HIV testing.
The third study done in Kenya reported that self-tests increased uptake in HIV testing by truck drivers, a traditionally hard-to-reach population. In the study, truck drivers were offered the options of supervised HIV self-testing, or self-testing later (taking a test kit with them), in addition to standard testing and uptake was compared to those offered standard only. While the difference was smaller than the other studies (14 percentage points or 2.8 times the odds), it is worth noting that these were men who were already at a physical clinic.
The fourth study was the FORTH study. Mohammed Jamil of the Kirby Institute in Australia presented results from an intervention that offered HIV self-tests to gay and bi-sexual men in Australia at higher risk of HIV. The intervention led to a two-fold increase in testing rates overall, and close to a four-fold increase in previously less-frequent testers.
What’s next for self-testing policies and programming?
The results of these pilot programmes should inform the efforts of governments and other implementers as they design programmes at scale, which they are starting to do. The Daily Nation reports that Kenya will be rolling out HIV self-testing by December and that the head of the National AIDS Control Council, Nduku Kilonzo, mentioned that HIV self-tests are one way to help close the testing gap to reach the first 90 of the UNAIDS goals and self-tests target “people who feel stigmatised and discriminated against, when they go to health facilities.”
There is still a need for more evidence, however. Some stakeholders continue to express concern about linkage to care from HIV self-tests and about the possibility for self-harm. Linkage to care is a challenge for all HIV testing. Currently, there is no evidence that linkage is worse for self-testing than for other testing modalities.
The concern about social or self-harm is often expressed by those who are hearing about self-testing for the first time. Brown, Djimeu and Cameron’s (2014) review of studies covering several kinds of self-tests found no evidence of social harm. In the few cases of intimate partner violence that have been reported, it is difficult to disentangle behaviour arising from testing positive from behaviour only arising because of self-testing.
Demonstration projects that carefully roll out HIV self-testing at scale and more impact evaluations of different implementation designs will be crucial for helping governments to approve and adopt HIV self-testing.
Forthcoming evidence
Several studies are underway now that will provide additional valuable evidence for policy and programming around HIV self-testing. Population Services International and partners are running demonstration projects and conducting research in Malawi, Zimbabwe, and Zambia, as part of the STAR project. They will expand to South Africa in the project’s second phase. 3ie is currently funding four additional HIV self-testing impact evaluations, two in Uganda and two in Zambia. In each country, one of the studies targets female sex workers with an emphasis on reaching sex workers in the places they frequent. In Uganda, the second study targets partners of antenatal-care clients. In Zambia, the second study targets the general population but using a door-to-door community health worker programme that can reach many hard-to-reach populations.
Prince Harry’s recent live-streamed HIV test resulted in a five-fold increase in demand for HIV self-tests from the Terrence Higgins Trust, an organisation in the United Kingdom that is piloting a testing initiative to reach men who have sex with men and black African people. We are, however, going to need more than that to reach the first 90 of the 90-90-90 goals. Supported by the exciting new evidence on HIV self-testing presented at AIDS 2016, many believe that HIV self-testing has the potential to access key populations at higher risk of HIV and other hard-to-reach populations and to boost HIV testing rates world-wide.